Sleep medicine is a new field, and some important aspect of sleep medicine coding changes almost every year. This review will focus on policies of the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration or HCFA. CMS pays for only 10-20% of a typical sleep center's studies, but CMS policy decisions influence other third-party payers.
Physicians can bill for services in diagnostic sleep testing in one of three ways. First, physicians providing services in their offices or freestanding sleep centers bill for the global service - both the professional work (interpretation) and the technical component - using the appropriate CPT code, such as 95810, without a modifier. Physicians interpreting diagnostic tests in hospital-based sleep centers or in some freestanding centers, will bill using CPT 95810-26; the -26 modifier means the bill is for the professional work only. Owners of some freestanding centers will bill for their technical fee as 95810-TC; the -TC modifier indicates that the bill is for the technical component of service only. Although freestanding centers and independent physicians may bill CMS for their separate component fees, most third party payers insist on getting a single bill, for the global fee.
Current CPT codes are listed in the following table. Codes 95806 and 95807, which do not require sleep staging, are termed "Sleep study." Codes 95808, 95810 and 95811, termed "Polysomnography," require sleep staging including electroencephalography (EEG) (1-4 leads), electro-oculography (EOG), and electromyography (EMG). In addition to sleep staging, code 95808 records 1-3 additional parameters of sleep, code 95810 records 4 or more additional parameters of sleep, and code 95811 records 4 or more additional parameters of sleep and CPAP use. New 2002 CMS policies for CPAP payment require that the sleep apnea diagnosis "must be based on a minimum of 2 hours of sleep recorded by polysomnography" (italics added), so the distinction between sleep studies and polysomnography is important to patient care.
Code 95806 describes an unattended sleep study, but all other codes require a technologist to be in attendance. (A home sleep study remotely monitored by an offsite technologist is not an attended study.) All codes require recording for 6 hours or more. The modifier, -52, may be used to code a limited service. For example, when a patient is intolerant to CPAP and stops a titration polysomnogram before 6 hours of recording has been completed, the procedure should be coded 95811-52. Tests performed to screen for a diagnosis, such as sleep apnea, must be coded with a "V" code - but CMS rarely pays for screening tests, even if a significant pathologic diagnosis is made.
| Sleep Testing Codes, CPT 2002 | |
| CPT Code | Description |
| 95805 | "Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness." |
| 95806 | "Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist." |
| 95807 | "Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist." |
| 95808 | "Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist." |
| 95810 | "Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist." |
| 95811 | "Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist." |
Some "Additional physiologic parameters" are listed in below. While CPT codes require that a certain number of parameters these parameters be recorded, the codes are not specific about the method of recording. For example, technologist observations of snoring intensity and body position may be adequate as two physiologic parameters of sleep for a polysomnogram.
ADDITIONAL PHYSIOLOGIC PARAMETERS, FOR POLYSOMNOGRAPHY | |
| EKG | Extended EEG |
| Airflow | Penile tumescence |
| Respiratory effort | GE Reflux |
| Gas Exchange by | Continuous BP monitoring |
|
|
| Limb muscle activity |  |
Based on a 2002 conversion factor of $36.20, the following table summarizes CPT requirements and CMS payment scale for diagnostic sleep studies and polysomnography.
Hospitals bill for the technical component of outpatient sleep studies under the relatively new system of Ambulatory Patient Classification (APC) Groups. To simplify coding and reimbursement for hospital outpatients, CMS grouped the CPT codes, numbering about 7500, into 451 APC codes. Each APC contains two to fifty (2-50) procedures. CMS established a national payment rate for each APC, adjusted geographically for the wage index. The payment includes costs for supplies, drugs, and room charges, but not professional fees, clinical lab fees, durable medical equipment, or rehabilitation services. The hospital is paid for each procedure based on the 1996 median hospital cost of all the services in the APC. One result is that book-keeping is simplified: hospitals bill for, and CMS pays for, only 451 separate fees rather than 7500 separate fees. Under the previous payment system, Medicare hospital outpatients were to pay 20% of hospital charges, but now benefit coinsurance will be gradually adjusted to 20% of the APC rate. Since charges often greatly exceeded hospital costs, hospital outpatients usually will pay lower fees under the new system.
For 2002, the technical charges for most sleep studies are in APC Group 0209 - Extended EEG Studies and Sleep Studies, Level II. The following sleep diagnostic tests are in this APC Group: 95805-TC, 95807-TC, 95808-TC, 95810-TC, 95811-TC. Among the prominent sleep testing codes, only the unattended sleep study is excluded. All-night sleep EEG, 24 hour EEG with video monitoring, and 24-hour EEG with computer analysis, are the only other codes in this group. The 2002 APC rate for the technical component of any service in this group is $537.
Also for 2002, CPT code 95806-TC, the technical component of the unattended sleep study, is in APC Group 0213 - Extended EEG Studies and sleep Studies, Level I. Five other EEG codes complete this group. The 2002 APC rate for the technical component of any service in this group is $135. CMS does not approve payment for CPT code 85806 when charged separately by a freestanding sleep center, but hospitals may be paid for performing this service on outpatients by billing the APC code.
Charges for pulse oximetry performed in the physician office should not be billed separately, but rather should be included as part of services during an office visit. An exception to this rule is CPT code 94762: "Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure)." The value of our organized lobbying was demonstrated when CMS restored separate reimbursement for overnight oximetry in response to comments by the Academy of Sleep Medicine - and when CMS decided to pay about $6.90 for it in 2002.
CPT code 99508 is "Home visit for polysomnography and sleep studies," conducted by a nonphysician. The CPT editorial panel in 2001 recommended that it be deleted.
A small but increasing number of physicians provide durable medical equipment through their office practice or freestanding sleep centers. Coding for PAP supplies is complex. To code for oral appliance therapy, including fitting, use CPT Code E1399: "Durable medical equipment, miscellaneous," or HCPCS Code S8620 "Oral orthodontic for the treatment of obstructive sleep apnea." CMS does not allow payment for oral appliances, but local insurers may approve reimbursement using one of these codes.
Clinicians and manufacturers for actigraphy, oral appliance therapy, pharyngometry, and other services have requested new CPT codes. Since the expansion of CMS funding is limited, it appears likely that payment for any approved new services will come from the sleep medicine "bucket," reducing payments for existing services.
To be eligible for Medicare payment a sleep study must be performed at a "sleep disorders clinic." The term is defined by CMS as a facility in a hospital or under the control of a medical director. CMS also requires that polysomnography and sleep studies be performed under the "general supervision" of a physician, meaning that the physician is responsible for the direction and control of the procedure, but the physician's presence is not required during the test.
In 1999 CMS published its policy for services performed in a facility independent of a physician's office or hospital, in a newly defined "Independent Diagnostic Testing Facility" (IDTF). For sleep testing to be performed in an IDTF, CMS requires that the physician supervisor be certified by boards in psychiatry and neurology, internal medicine with pulmonary subspecialty, or in sleep medicine. CMS also requires that IDTF technologists must be certified in electroneurodiagnostic testing or registered in polysomnography.
To pay for CPAP, CMS previously required that a patient have "30 apneas" per 6 hours of recording. Under a new 2002 policy, CPAP will be approved for patients with an apnea/hypopnea index (AHI) of 15 or more, and for patients with an AHI of 5-14 "with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke. The AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep (i.e. the AHI may not be extrapolated or projected). Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thorocoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. The polysomnography must be performed in a facility-based sleep study laboratory, and not in the home or in a mobile facility."
This revised CPAP payment policy tasks referring physicians to order polysomnography, not sleep studies, to diagnose sleep apnea. If CMS interprets this policy literally, any diagnosis made using data from a 4-channel cardiorespiratory "sleep study" or from home "polysomnography" must be confirmed by an attended polysomnogram in the laboratory, possibly in a split-night protocol. The policy puts new burdens on testing facilities to revise their scoring rules to comply with CMS definitions, and to ensure that split night studies include a baseline of 2 hours of sleep. Since it is unlikely that facilities will use separate scoring rules only for Medicare patients, most facilities now must standardize their definition of hypopnea. To reduce difficulty for the patient, DME provider and prescribing physician, each report should clearly state the facility scoring conventions, the technical description of the recording, the patient's symptoms, the number of apneas, and the AHI.
Not only must the interpreting physician code the study correctly - effective January 1, 2002, "a new [CMS] national policy states that a doctor who interprets it should bill using the ICD-9 code for the final, related diagnosis - not the reason for the test... symptoms that prompted the ordering of the test may be reported as additional diagnoses." Releasing this policy, CMS has reinforced the primacy of ICD-9-CM for diagnostic coding and has reinforced the injunction to code to the highest level of accuracy and specificity. The same policy also requires that a testing facility must document the testing order from the referring physician.
Sleep specialists are faced with two sets of diagnostic coding. The ICSD - International classification of sleep disorders: Diagnostic and coding manual, edited by Thorpy, was published by the American Sleep Disorders Association, now the AASM, in 1990. A revised edition was published in 1997, and an update process has begun. The ICSD has been very helpful for sleep specialists and for sleep research, but most medical specialties and insurers rely on the International Classification of Diseases, 9th revision, Clinical Modification - the ICD-9-CM. The tenth revision of ICD is due in 2002. Most clinicians use ICD-9-CM coding for clinical purposes, since insurers rely on it to match services with diagnoses, and since Medicare requires the ICD-9-CM code. Note, however, that the AASM may require accredited centers to use the ICSD diagnostic codes. The following table lists some common sleep disorders and their codes. Some notes on coding:
- There is no separate ICD-9-CM diagnostic code for central sleep apnea. Code for obstructive or central sleep apnea depending on whether the patient has insomnia or hypersomnolence.
- There is no specific ICD-9-CM code for primary snoring without significant sleep apnea. The suggested code is a nonspecific code under "Symptoms involving respiratory system and other chest symptoms."
- The suggested ICD-9-CM code for restless legs syndrome is a nonspecific code under "Other extrapyramidal disease and abnormal movement disorders,"" but the definition of the nonspecific codes mentions the condition: "333.99, Other, Restless legs." This may also be the best code for periodic limb movement disorder, a movement disorder occurring during sleep, which is not specifically listed in ICD-9-CM.
- There is no specific ICD-9-CM code for idiopathic insomnia as defined in the ICSD. Specific codes for transient or persistent insomnia are listed in ICD-9-CM "307.4 Specific disorders of sleep of nonorganic origin."
| Clinical Diagnosis | ICSD Code | ICD-9-CM Code |
| Obstructive sleep apnea syndrome | 780.53-0 | 780.51 Insomnia with sleep apnea 780.53 Hypersomnia with sleep apnea 780.57 Other and unspecified sleep apnea |
| Central sleep apnea syndrome | 780.51-1 | 780.57 Other and unspecified sleep apnea |
| Primary snoring | 780.53-1 | 786.09 Other Excludes respiratory distress and failure |
| Narcolepsy | 347 | 347 Narcolepsy |
| Restless legs syndrome | 780.52-5 | 333.99 Other Restless legs |
| Periodic limb movement disorder | 780.52-4 | 333.99 Other Restless legs |
| Idiopathic insomnia | 780.52-7 | 780.52 Other insomnia Insomnia NOS |
Private insurers often develop proprietary coverage policies about sleep medicine, and they often do not disclose them freely. Aetna/US Healthcare, to its credit, has posted its "Coverage Policy Bulletin" on its website. Local professional relationships are important to the sleep center and to the insurers; with persistence and good will, we can help the insurer medical directors to develop policies helpful to our patients. Please help to influence national sleep medicine policies: join the American Medical Association and register as a specialist in sleep medicine, join the AASM, and contribute to the AASM's Political Action Committee.
References
- Raphaelson, M. Sleep Center Management. AASM 1998. 2nd ed 2000.
- Inglehart, J. The Centers for Medicare and Medicaid Services. NEJM 345: 1920-1924, 2001.
- Tunis, S. et al. Continuous Positive Airway Pressure (CPAP) Therapy Used in the Treatment of Obstructive Sleep Apnea: Coverage Decision Memorandum for CPAP, 2001. http://www.hcfa.gov/coverage/download/8b3-bbb1.rtf
- ICSD - International classification of sleep disorders: Diagnostic and coding manual. Diagnostic Classification Steering Committee, Thorpy MJ, Chairman. Rochester, Minnesota: American Sleep Disorders Association, 1990.
- International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) 6th Edition (2001 Update. Department of Health and Human Services, National Center for Health Statistics (NCHS). October 1, 2001.
- Medicare Part B News.15:pages 1 and 7, October 1, 2001. Policy B-01-61 is available through: http://www.partbnews.com
- Shepard, John. President's Perspective. AASM Bulletin, 4-5, Winter 2002. (Discusses the 2002 CMS CPAP payment rules.)
Attribution
Marc Raphaelson, MD is medical director for Greater Washington Sleep Disorders Centers in Metropolitan Washington, DC. He is a member of the AASM's Health Policy Committee.
Marc Raphaelson, MD
Greater Washington Sleep Disorders
Washington, D.C.
